How to make your EHR work for you

Physicians have been dealing with the frustrations of electronic health record systems for years. EHRs are widely seen as a hindrance, not a help, but does it have to be that way? Not necessarily.

“I think people have to move beyond ‘it’s a necessary evil’ and get to the point of ‘this is here to stay and how do I get it to work for me?’ ” said Steven M. Schlossberg, MD, MBA, chair of the AUA Data Committee and vice president and chief medical information officer at John Muir Health in Northern California.

Dr. Schlossberg is not alone in suggesting that there are ways to make the most of EHRs. Urology Times asked experts and EHR users for practical tips, fixes, advice, and workarounds that might help urologists ease EHR-associated frustrations.

Scope of the problem

About a decade into the widespread adoption of EHRs, physicians continue to report their dislike for the technology. In Urology Times’ 2018 State of the Specialty survey, use of EHRs was the number one factor that contributed to urologists feeling burned out. About one-third of urologists said they spend 10-19 hours per week and another 22% spend 20-29 hours per week entering data in their EHR, the survey showed.

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“EHR usability, which is the extent to which this technology can be used efficiently, effectively, and safely by clinicians to deliver care, has emerged as one of the most pressing issues in health care,” according to an article published in JAMA (2018; 320:2533-4).

The EHR is the central nervous system at most urology practices, making frustrations with the technology an hourly event for urologists, said Robert A. Dowling, MD, a urologist and board-certified clinical informaticist, principal of Dowling Medical Director Services, and the former medical director of a large metropolitan urology practice.

“The most common complaint that physicians have with their EHRs is that they just can’t navigate or accomplish repetitive tasks in as short a period of time as they’d like. They’ll verbalize it as too many clicks or some placement of content in their workflow that’s not intuitive,” Dr. Dowling said.

But EHRs weren’t developed to mirror the urologist’s thinking or clinical workflow. The technology was created to facilitate compliance and reimbursement in the U.S. health system, according to Dr. Dowling.

One of the problems with EHRs is that physicians tend to think their primary function is to help them generate and review progress notes. In reality, EHRs remain reimbursement tools and not so much clinical documentation tools, he said.

Next: Adjust your mind-set

Focusing on using EHRs for progress notes might cause physicians to underutilize good tools EHRs have to offer, Dr. Dowling said.

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“Examples of that would be the patient portal and communicating with patients electronically through that system to answer questions, process medication refills, or release patients’ labs. All these things have a return on investment in that they save the office staff time, reduce inbound phone calls to the practice, and those sorts of things,” he said.

Advanced EHR functions include the ability to integrate a practice’s electronic medical record with its billing and scheduling software; indicate the level of billing for a patient encounter; e-prescribe and generate correspondences to referring physicians; and create templates for common histories and common treatment plans, according to Aaron Spitz, MD, a partner in Orange County Urology Associates, Laguna Hills, CA, and a voluntary assistant clinical professor of urology at the University of California, Irvine.

“An important functionality that’s not unique to any EHR is the ability to preserve your records from physical destruction by having them backed up in another location or in the cloud. That became very relevant to our practice a few months ago when we had a devastating fire in our central hub,” Dr. Spitz said. “Having an EHR that has a backup in the cloud or simultaneous real-time off-site backup can be critical.”

Customize-but not too much

Urology practices should aim to have fundamental aspects of the EHR maximized for the practice’s workflow. That means the practice needs to be engaged with the people who are configuring the system, according to Dr. Schlossberg.

“It’s making sure that the EHR is personalized across the practice in order to leverage the EHR for how it’s best used, which is to automate certain routine tasks,” Dr. Schlossberg said.

Urologists, however, should balance their desires to customize EHRs with allowing the technology to do what it’s supposed to do.

“The closer you can stay to the foundation or to the vendor-delivered solution, the better,” Dr. Schlossberg said.

Urologists should go to the training classes and invest the time they need to become proficient, said Peter C. Albertsen, MD, professor of urology at the University of Connecticut, Farmington.

“You will be clumsy and frustrated in the beginning,” Dr. Albertsen wrote in an email to Urology Times. “Make sure your institution or vendor continues to provide support for 1 year. You will be amazed at the numbers of small problems and issues you will encounter that must be addressed, but occur infrequently. Talk to your colleagues. This is the best way to learn shortcuts and workarounds.”

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Practices should also charge one or more people who are engaged EHR users to help other staff learn and best use the system. Staff education is key for optimal EHR use, according to Dr. Schlossberg.

Next: Create templates

When using an EHR, it’s not always necessary for urologists to reinvent the wheel. Prepopulating templates for standardized care in a practice can increase efficiency, Dr. Schlossberg said.

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Jim Kovarik, PA-C, a physician assistant and EHR super user at the University of Kansas Health System, Kansas City, said creating templates requires time initially but saves time in the long run. He recommended practices create custom templates and orders for as many types of orders as possible, such as common lab, radiology, and medication orders.

“I believe it speeds up ordering during clinic and minimizes order confusion, which can generate additional phone calls from the patient, lab, or radiology department later,” Kovarik said.

Kovarik said he also uses prepopulated templates for common discussions or patient instructions, for which providers use the same language or have the same discussion in every circumstance. That can speed up documentation. But these and other prepopulated templates have to be edited for the specific patient or clinical scenario at that time, he said.

Urologists’ ability to create templates or subroutines is built into EHRs, according to Dr. Spitz.

“A very common one that I use is a discussion of risks and benefits of a surgical procedure. I’ll have that discussion in the room with the patient. It can be a lengthy discussion. So, I don’t have to spend the same amount of time typing out a re-creation of that discussion. If there are any modifications, I can add those with a few words here or there, but I don’t have to re-create the conversation every time,” Dr. Spitz said.

The goal of using templates is to improve efficiency while maintaining accurate patient records. It’s not to cut and paste without reviewing the information to make sure it’s accurate and current, according to Brianne Goodwin, JD, RN, manager of clinical risk and patient safety at Cambridge Health Alliance, Cambridge, MA.

Pulling information that’s not current and accurate can multiply quickly, ending up in progress notes or as a surgical op note, among other places, Goodwin said.

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“Things that are static like a patient’s date of birth are certainly helpful in reducing waste and time, but it’s a little bit more of a risk pulling information that is likely to change or could change,” she said.

Next: Utilize passive documentation

Tools that passively document while physicians interact with patients can help alleviate documentation frustrations. Options include having an actual scribe in the room, as well as virtual scribes who are connected through a microphone, camera, or both.

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“Voice recognition software has gotten very good. It doesn’t require training anymore. Those physicians who are facile-more facile with dictating than typing or clicking-are finding that it’s quicker and faster than it used to be and definitely more accurate than it was, say, 5 years ago,” Dr. Dowling said.

There are considerations with these workarounds, however.

Having a scribe should not take the place of understanding how to use the EHR, according to Dr. Schlossberg.

“Although scribes are valuable, I think they’re most valuable in combination with the physician really understanding the EHR,” he said.

There might also be legal implications associated with using a scribe-whether in person or virtually, according to Goodwin. The medical scribe field, she said, is a highly unregulated field of employment, and urologists should understand scribes’ limitations and possible pitfalls. For example, scribes’ level of expertise and knowledge of medical terminology is not standard.

“Some people refer to it as the Wild, Wild West,” Goodwin said. “But it’s also an area where hiring is happening at a very fast rate because they have been felt to be very helpful for office efficiency and to be able to get more eye-contact time with patients rather than staring at the screen and typing.”

Urologists who use voice recognition software can avoid potentially costly mistakes by proofreading their notes, she said.

“Make sure that a urethra is not a ureter. Sound-alike words should be proofed, and make sure the note is only signed after it has been read,” Goodwin said.

Dr. Dowling suggested that urologists don’t use the progress note section to store information they might review in the future. They should instead use the notes section of a problem list or other option.

“That way, they don’t have to scroll through or review all the notes that they’ve created in the past,” Dr. Dowling said.

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And urologists who haven’t should convert to electronic superbills. Why? Dr. Dowling says electronic superbills increase billing efficiency.

Next: Relief in sight

The Centers for Medicare & Medicaid Services has announced that it is relaxing documentation requirements for different levels of evaluation and management codes.

“In 2 years, there will be no difference in documentation for levels 2, 3, and 4. And that means that physicians need to focus less on documenting information only for billing purposes that they don’t use for clinical purposes,” Dr. Dowling said.

EHRs’ roles in physicians’ work days will increase, according to Dr. Dowling.

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As health care evolves to what many predict will be a disease management model in which urologists and others care for panels of patients using several means, including virtual care and telemedicine, EHRs offer functions that should streamline all aspects of that care, including in the office and on the phone, he said.

Learn more about EHR best practices

Urologists and others interested in learning more about EHR best practices can refer to the Arch Collaborative by KLAS Research, which is a health care IT data and insights company. The Arch Collaborative is a worldwide provider-led initiative to improve EHR usability and satisfaction through measurement, benchmarking, and collaboration around best practices, according to KLAS Research. For more information, see www.klasresearch.com/arch-collaborative.